Provider Management. Current MCOs shall maintain effective communications with its providers.
1. Current MCOs that are not selected as Centennial Care 2.0 MCOs shall:
(a) Inform providers, in writing, at least sixty (60) calendar days prior to January 1, 2019, of the termination of their respective contracts and of the process for providers to submit claims for services provided through December 31, 2018, but submitted after that date. The letter shall be submitted to HSD for review and approval at least thirty (30) calendar days prior to its issuance to providers and must include at a minimum, the following for claims submissions:
(1) Contact information (including telephone and fax numbers);
(2) Billing address;
(3) Electronic submission instructions (if different than billing address) for claims submissions; and
(4) Designated point of contact for questions.
(b) Allow providers the following timeframes to submit claims for services provided prior to January 1, 2019:
(1) 120 calendar days from date of service to submit original claims;
(2) 90 calendar days from the paid date for adjusted claims;
(3) 210 calendar days from the date of service for claims that have third-party liability or are Medicare crossover claims; and
(4) 730 calendar days from the date of service for I/T/Us to submit any claim.
(c) Continue to meet the timeframes established by contract for processing all claims and submission of encounters to HSD; and
(d) Meet all regulatory requirements regarding notification to HSD of terminated providers.
2. All MCOs, including any Current MCOs selected for Centennial Care 2.0 must develop provider networks as required under the Centennial Care 2.0
Provider Management. The Provider Management business area is a collection of business processes that focus on recruiting potential providers, supporting the needs of the population, maintaining information on the provider, and communicating with the provider community. The goal of this business area is to maintain a robust provider network that meets the needs of both beneficiaries and provider communities and allows the Commonwealth Medicaid agency to monitor and reward provider performance and improve healthcare outcomes. The Commonwealth provides most of its Medicaid services through MCOs. The Provider business processes serve as the control point and central source of information on all providers and provider applicants. Files are maintained that provide comprehensive information on each provider, billing agency, trading partner, and provider group participating in the Commonwealth programs. MEMS solution shall provide access to all Provider Management functionality related to all Medicaid Providers and Provider Organizations through Commonwealth’s self service Provider Portal. Commonwealth’s self service provider portal, under development using Microsoft .net technology, will provide functionality related to enrollments and eligibility enquiries. The transition between the MEMS solution and Commonwealth’s Self Service portal should be transparent and seamless to the end users with no additional logins. The MEMS solution shall be responsible for including but not limited to:
1. Submit original claims, claim adjustments and prior approval requests.
2. Review claims payment and status information.
3. Access Prior approval requests.
4. Access State-approved forms.
5. Access provider training information including provider workshop registration, training materials, training evaluation forms, bulletins, broadcast emails, supporting documentation for training.
Provider Management. Contractor shall capture, manage, and maintain information for the State’s prospective or enrolled health care Providers (“Providers”) and support Provider eligibility determination and enrollment business processes. Contractor shall support communications between the State and the prospective or enrolled Providers. Communication management functions include functions such as: Provider correspondence and notifications, outreach and education, enrollment and revalidation, and Provider appeal management and tracking within the Provider Management Module (PMM) system. Contractor shall maintain PMM Software as a Service (SaaS) solution consisting of multiple modules hosted in a cloud platform. The system serves the Vermont Provider community and the State by enabling the following: Provider Enrollment, Provider Screening and Workflow, Provider Portal for data maintenance, and Provider Management for internal user access to Provider records. Contractor shall make PMM periodic SaaS releases and software updates available to the State. Contractor shall coordinate with the State on periodic release projects to ensure the State remains on a supported version of the solution. Contractor shall publish software documentation specific to each PMM release including release schedules, release notes, and software documentation. Each release of PMM functionality shall follow testing best practices and key test levels to include System Integration Testing and User Acceptance Testing, and standardized defect management processes. Contractor shall provide services and applications to support Provider Management, including but not limited to the following impacted MITA Business Processes:
i. EE05 Determine Provider Eligibility ii. EE06 Enroll Provider iii. EE07 Disenroll Provider iv. EE08 Inquire Provider Information v. PM01 Manage Provider Information vi. PM02 Manage Provider Communication
Provider Management. The Contractor shall assign responsibility and establish procedures to monitor, manage and continuously improve the performance of its provider network. These procedures shall ensure that:
C.9.4.2.1 Each hospital participating in the Contractor's network complies with the requirements of Section 1867 of the Social Security Act, 42 U.S.C. Section 1395dd (Anti-dumping);
C.9.4.2.2 The network provides services of acceptable quality, accessibility, and efficiency;
C.9.4.2.3 Each physician providing EPSDT services is evaluated annually to determine whether he or she has the necessary equipment and knowledge to perform such services in accordance with standard medical practice;
C.9.4.2.4 Advances in medical practice are implemented promptly and consistently in accordance with industry standard;
C.9.4.2.5 Providers receive information (provider profiles) on their performance on key aspects of their practice in comparison to benchmarks. The Contractor shall specify in its Quality Management Plan its goals for profiling providers and establishing benchmarks and shall comply with reporting requirements specified in Section F; and
C.9.4.2.6 Unacceptable provider performance or indications of fraud and abuse are promptly identified, addressed, documented and reported to MAA Offices of Program Integrity, Managed Care and District OIG Office of Medicaid Fraud and Abuse.
Provider Management. The Users with the role of Provider Organisation Administrator can perform the following activities for the management of their organisation: Edit organisation details View the users registered within the Provider organisation Edit the UNSPSC codes registered for the Provider Add new users to the Provider organisation Edit user’s details Export Auditing Reports This management functionality is provided through the “Provider Management” option of the “Provider Administration” menu.
2.11.1 Edit Organisation Details
